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. 2022 Jun 1;5(6):e2217704.
doi: 10.1001/jamanetworkopen.2022.17704.

Patient Symptoms and Stress Testing After Elective Percutaneous Coronary Intervention in the Veterans Affairs Health Care System

Vinay Kini  1 , Monica Parks  2 , Wenhui Liu  3 , Stephen W Waldo  2   3   4 , P Michael Ho  2   3 , Steven M Bradley  5 , Paul L Hess  2   3
Affiliations

Patient Symptoms and Stress Testing After Elective Percutaneous Coronary Intervention in the Veterans Affairs Health Care System

Vinay Kini et al. JAMA Netw Open. .

Abstract

Importance: Up to 60% of patients in the US receive a stress test within 2 years of percutaneous coronary intervention (PCI), prompting concerns about the possible overuse of stress testing.

Objective: To examine the proportion of patients who underwent stress testing within 2 years of elective PCI, proportion of patients who had symptoms that were consistent with coronary artery disease (CAD), timing of stress testing, and site-level variation in stress testing among symptomatic and asymptomatic patients.

Design, setting, and participants: This cohort study used administrative claims data and clinical records from the US Department of Veterans Affairs (VA) Clinical Assessment, Reporting, and Tracking program. Patients who underwent stress testing within 2 years of elective PCI for stable CAD between November 1, 2013, and October 31, 2015, at 64 VA facilities were included in the analysis. Patients who received stress testing for staging purposes, cardiac rehabilitation evaluation, or preoperative testing before high-risk surgery were excluded. Data were analyzed from June to December 2020.

Main outcomes and measures: The main outcome was the proportion of patients who underwent stress testing and had symptoms that were consistent with obstructive CAD, using definitions from the 2013 clinical practice guideline (Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease). Secondary outcomes were the timing of stress testing (assessed using a cumulative incidence curve) and site-level variation in stress testing (assessed using multilevel logistic regression models).

Results: A total of 3705 consecutive patients (mean [SD] age 66.3 [7.6] years; 3656 men [98.7%]; 437 Black individuals [11.8%], 3175 White individuals [85.7%], and 93 individuals [2.5%] of other races and ethnicities [Asian, Hispanic or Latinx, or unknown]) had elective PCI. Of these patients, 916 (24.7%) received a stress test within 2 years, among whom 730 (79.7%) had symptoms that were consistent with obstructive CAD at the time of stress testing. Visual inspection of a cumulative incidence curve for stress testing showed no rapid increases in stress testing at 6 months or 1 year after PCI, which might coincide with routine clinical visits. The proportion of symptomatic patients who underwent stress testing at each VA site ranged from 67.7% to 100%, with no significant site-level variation in stress testing.

Conclusions and relevance: Results of this study suggest that most veterans who underwent stress testing within 2 years after elective PCI had symptoms that were consistent with obstructive CAD. Therefore, measuring low-value stress testing using only administrative claims data may overestimate its prevalence, and concerns about overuse of post-PCI stress testing may be overstated.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Kini reported receiving grants from National Institutes of Health outside the submitted work. Dr Hess reported receiving grants from the US Department of Veterans Affairs (VA) Health Services Research and Development and grants from the American Heart Association outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Site-Level Variation in the Estimated Proportion of Stress Testing Among Symptomatic Patients
Minimal site-level variation in the proportion of symptomatic patients who received stress tests within 2 years of percutaneous coronary intervention was observed using multilevel regression models.
Figure 2.
Figure 2.. Cumulative Incidence of Stress Testing After Elective Percutaneous Coronary Intervention (PCI)
A steady linear increase in the incidence of stress testing was observed, without rapid increases in stress testing at usual follow-up clinical visits (ie, 6 months and 1 year).
See this image and copyright information in PMC

References

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